Behaviour change

Professor Susan Michie, who's at University College London, is an expert in behaviour change and her research is in health psychology and health services. She talks with Lynne Malcolm about her work in this area.

Transcript

Norman Swan: Visiting Melbourne recently was an expert in behaviour change, Susan Michie, who's Professor of Health Psychology at University College London. She spoke to Lynne Malcolm.

Susan Michie: The starting point for thinking about behaviour is to think about three aspects of behaviour: motivation, opportunity, capability. And for any behaviour to occur, the person has to have the psychological and physical capability, they have to have the social and physical opportunity, and also they need to be motivated. Every behaviour has to be understood in its context, and so it's quite difficult to generalise.

A large problem all over the world is healthcare professionals keeping their hands clean. One might think that behaviour is very simple, just to rub some alcohol hand-rub gel or soap into their hands. But we know from research literature that on average nurses and doctors clean their hands appropriately on only 40% of occasions that they should. Work that we've done in the UK has shown problems in the capability, the opportunity and the motivation, and we've run a campaign over the last few years quite successfully called Clean Your Hands campaign. We targeted all those three components of behaviour.

So in terms of the opportunity, we ensured that there was alcohol hand-rub gel beside every bed, so every health professional had the opportunity to clean their hands. In terms of motivation, we ensured that there was a component in training and also we had motivational posters throughout the hospitals that were designed by groups within the hospital, and those were changed every two weeks, to try and tap the motivation.

And in terms of the capability—and by this I mean the capability, when the nurse has competing demands, to be able to be aware and think through and prioritise that behaviour over others—we instituted a feedback intervention whereby nurses were observed and if they weren't cleaning their hands on all the occasions they should, they immediately were getting feedback, asked to reflect on why they didn't, and come up with an action plan as to how they'd do things differently. We've evaluated that through 60 wards across 16 hospitals, and shown that multi-levelled intervention, tapping all three components of capability, motivation, opportunity, resulted in more use of hand-rub gel and soap on the wards, higher percentage of people cleaning their hands when they should have, and we were able to show reduced infection rates.

Lynne Malcolm: To what extent is something like hand hygiene dependent on how socially acceptable it is to not wash your hands?

Susan Michie: Well, really all staff sign up to the fact that it's a good idea. They all intend to. It's just that behaviour occurs 'in the moment', and there are often competing demands. But you have other situations where there's not so much acceptance that this is a really high priority. To give an example of that, we conducted a study in motorway toilets, and we were able to wire up the toilet so that we had beams across the front of the door so that we knew how many people were using the toilets, and we also knew how many times people were using the soap. We had that electronically monitored. And so we were able to look 24 hours a day, seven days a week at the percentage of people who were using the toilets who were also using soap. That was very instructive, and the rates weren't high. And they were much lower in the men's toilet than the women's toilet.

One of the things we did was to have an electronic display with different kinds of messages that were based on research, to see which messages would have which impacts on hand washing. One of the ones that was quite effective gave a rather yuck factor, the kind of disgust factor.

Lynne Malcolm: Can you give an example of what has been a really successful behaviour intervention in the past, and why that was so successful?

Susan Michie: One of the big success stories, both in Australia and the UK, is tobacco control. We know from research evidence that if one intervenes in many different ways simultaneously it's going to have more impact. So the comprehensive strategy includes everything from legislation, regulation, tax measures, changing the environment, as well as communication and marketing, to persuade people that it's a good thing, and providing services to help people quit.

If you go back to the model of behaviour I was talking about earlier—capability, opportunity and motivation—you can see that that kind of strategy changes opportunity, because if there's no longer smoking in public places there's less opportunity, and if cigarettes are kept below the counter, similarly. It also influences motivation with some very good communication and marketing strategies, and also influences capability by actually supporting people to develop skills for resisting craving and preventing relapses and offering medication that helps with the physical capability.

Lynne Malcolm: Could we use the example of the obesity epidemic, and how might that model apply to that?

Susan Michie: Lessons need to be learned from the success of the tobacco control story, and this will require government taking a more proactive stance in terms of advertising, marketing and regulation of unhealthy foods. So there are many rooms for improvement that could quite easily be achieved if one was ensuring that the industry was being regulated, that the tax system was being used, and other policy approaches were being used at the same time as the basic intervention strategies of education and persuasion.

Lynne Malcolm: So are you suggesting that in the obesity example that perhaps individual motivation doesn't have as much power in the combination as capability and opportunity because of the industry background?

Susan Michie: I think that's right. Most people who are overweight do not want to be overweight. The problem is that we have allowed an obesogenic environment to develop. And so it's extremely difficult not to put on weight. And those who succeed are usually monitoring their weight continually, regulating their behaviour in terms of resisting the high calorific foods that are so available and so cheap all around us, and taking steps to be more physically active than most people's lifestyles generally permit.

So then the key things are absolutely the environment, the physical and the social opportunities afforded to people, and beginning to regulate and restrict the damaging types of foods, and doing more to make accessible, available, affordable the more healthy kinds of food. So the opportunity is key and that's something where government has a big responsibility, and alongside that there is also more room for improvement in terms of helping individuals to regulate their behaviour in terms of resisting the attractiveness of the unhealthy foods around them. And quite simple things.

For instance, in supermarkets not having the chocolates and the crisps on the low shelves and where you're waiting at the checkout. So, from supermarket level right up to television, to advertising, to the price structure of different kinds of foods. Providing the equivalent of what we provide for stop-smoking services. It's very, very important not to say this is due to individual weakness and individual failure. The main problem is that we have allowed an obesogenic environment to develop.

Norman Swan: Susan Michie is Professor of Health Psychology at University College London and was speaking to Lynne Malcolm.